ADMINISTRATIVE CHANGE FORM PUBLIC OR SEMI-PUBLIC SWIMMING POOL OR SPA

2. ENVIRONMENTAL SERVICES
   DEPARTMENT

   Steven J. Goode, REHS, M.A., Director<br>1001 N. Central Avenue<br>Phoenix, AZ 85004 - 1937

   Steven J. Goode, REHS, M.A., Director
   1001 N. Central Avenue
   Phoenix, AZ 85004 - 1937

3. 

4. WATER AND WASTE MANAGEMENT
   DIVISION

   Kevin S. Chadwick, PE, Division Manager<br>1001 N. Central Avenue, Suite 200<br>Phoenix, AZ 85004 – 1937 Fax (602) 506-1837

   Kevin S. Chadwick, PE, Division Manager
   1001 N. Central Avenue, Suite 200
   Phoenix, AZ 85004 – 1937 Fax (602) 506-1837

6. ADMINISTRATIVE CHANGE FORM
   PUBLIC OR SEMI-PUBLIC SWIMMING POOL OR SPA

   Permits are not transferable. This form can be used to change/update the management company or/and billing address. If the owner has changed, please complete the "New Owner Application" online form below.

   Permits are not transferable. This form can be used to change/update the management company or/and billing address. If the owner has changed, please complete the "New Owner Application" online form below.

8. New Owner Application

   New Owner Application

12. FACILITY INFORMATION

14. 1. Facility Name:*

16. 2. Business Address:*

17. City:*

18. Zip:*

20. 3. Facility Contact Name:

21. Phone #:

23. 4. Email Address:

27. OWNER’S INFORMATION

29. 6. OWNERS Name*:*

    *Owner listed should match what is listed for your business license and tax id.

30. Phone #:

32. 7. Address:

33. FAX #:

35. 8. City:

36. State:

37. Zip:

39. 9. Email Address:

41. 10. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
43. Owner Signature:

47. BILLING/MAILING INFORMATION

49. 12. CONTACT Name:*

50. Phone #:*

52. 13. Management Company/Agent Name:*

53. Phone #:

55. 14. Address:*

56. FAX #:

58. 15. City:*

59. State:*

60. Zip:*

62. 16. Email Address:*

Leave This Blank:


64. 1. Receive email copy
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

* indicates a required field